Authorization Form for Release of Health Information to Planned Parenthood

AUTHORIZATION FORM FOR RELEASE OF HEALTH INFORMATION TO PLANNED PARENTHOOD

Name:

(Last) (First) (Middle Initial) (Maiden or other)

Date of Birth: Medical Record Number (if known):

Address: City: State: Zip:

Day Phone: Alternative Phone:

I HEREBY AUTHORIZE THE FOLLOWING RELEASE OF MY PROTECTED HEALTH INFORMATION:

RECORDS REQUESTED FROM: SEND RECORDS TO:

Planned Parenthood League of Massachusetts

Clinic/Provider Clinic/Provider

1055 Commonwealth Ave

Address Address

Boston MA 02215

City State Zip City State Zip

617-616-1600 617-616-1618

Phone Number Fax Number Phone Number Fax Number

HEALTH INFORMATION TO BE RELEASED:

This authorization is made for the following purpose:

ð At my request, OR Specify: ð Insurance ð Medical Care ð Legal Matter ð Other: ____________________________

I hereby specifically authorize release of the following information for treatment dates: _________________ to: ________________

ð Records from most recent visit and related lab reports

ð Abortion Procedure records and related lab reports

ð Records related to Pap Smears (including follow-up and treatment)

ð Sexually Transmitted Diseases test results

ð HIV-related information (AIDS-related testing)

ð Radiology Reports (i.e. ultrasounds)

ð Lab result information

ð Other: _____________________________________________

CONDITIONS OF AUTHORIZATION

1. This Authorization will expire 90 days from the date of my signature, unless I have indicated differently:

This release will expire on: _________________________________ (date written by patient).

2. I may revoke this Authorization at any time by notifying Planned Parenthood League of Massachusetts in writing, and it will be effective on the date notified except to the extent that Planned Parenthood League of Massachusetts has already acted upon such Authorization.

3. Information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer protected by Federal privacy regulations.

4. By authorizing this release of information, my healthcare and payment for my healthcare will not be affected if I do not sign this Authorization form.

5. I have been offered a copy of this signed Authorization form.

Signature of Patient Date

or

Parent/Legal Guardian/Authorized Person Date